botulinum toxin injection guid
TRANSCRIPT
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I B R . O D D E R S O N
I N J E C T I O N G U I D E
S P A S T I C I T Y
D Y S T O N I A
M I G R A I N E
H Y P E R H I D R O S I S
D R O O L I N G
P A I N
R A T I N G S C A L E S
C O D I N G / B I L L I N G
BOTULINUM
TOXIN
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BOTUL INUM TOX INI N J E C T I O N G U I D E
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BOTULINUM TOXINI N J E C T I O N G U I D E
Ib R. Odderson, MD, PhDAssociate ProfessorUniversity of Washington Medical Center
Seattle, Washington
Medical Publishing
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Acquisitions Editor: R. Craig Percy
Cover Designer: Steve Pisano
Indexer: Christine Lindemer
Compositor: Lapiz Digital Services
Printer: Malloy Litho
Visit our web site at www.demosmedpub.com
2008 Demos Medical Publishing, LLC. All rights reserved. This book is protected
by copyright. No part of it may be reproduced, stored in a retrieval system, or
transmitted in any form or by any means, electronic, mechanical, photocopying,
recording, or otherwise, without the prior written permission of the publisher.
Library of Congress Cataloging-in-Publication DataOdderson, Ib R.
Botulinum toxin injection guide / Ib R. Odderson.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-1-933864-21-1 (pbk. : alk. paper)
ISBN-10: 1-933864-21-4 (pbk. : alk. paper)
1. Botulinum toxin--Therapeutic use--Handbooks, manuals, etc. I. Title.
[DNLM: 1. Botulinum Toxins--administration & dosage. 2. BotulinumToxins--therapeutic use. 3. Injections--methods. QW 630.5.B2 O22 2008]
RL120.B66O33 2008
615.788--dc22
2007052989
Medicine is an ever-changing science undergoing continual development. Research
and clinical experience are continually expanding our knowledge, in particular
our knowledge of proper treatment and drug therapy. The authors, editors, and
publisher have made every effort to ensure that all information in this book is inaccordance with the state of knowledge at the time of production of the book.
Nevertheless, this does not imply or express any guarantee or responsibility on the
part of the authors, editors, or publisher with respect to any dosage instructions and
forms of application stated in the book. Every reader should examine carefully the
package inserts accompanying each drug and check with his physician or specialist
whether the dosage schedules mentioned therein or the contraindications stated by
the manufacturer differ from the statements made in this book. Such examination
is particularly important with drugs that are either rarely used or have been newlyreleased on the market. Every dosage schedule or every form of application used is
entirely at the readers own risk and responsibility. The editors and publisher welcome
any reader to report to the publisher any discrepancies or inaccuracies noticed.
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08 09 10 11 5 4 3 2 1
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To
Ingrid, Erik, and Eva
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George H. Kraft, MD,has been a mentor and a good friend since the
beginning of my residency program at the University of Washington,
Seattle. He is a breath of fresh air, always optimistic, inspiring, and
fun to be around. He is truly an academic statesman, has advised
me well, and opened many doors for me. Thank you, George.
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Acknowledgments
I would like to thank the following people for their help. George H. Kraft,
MD, professor, for his help in connecting me with all the right people.
R. Craig Percy, senior medical editor, for his advice and support with this
project.Jennifer Smith, medical illustrator, for her hard work and artistic
skill in rendering the illustrations for this book. Gerard Francisco, MD,
adjunct associate professor, for kindly reviewing the manuscript and
his thoughtful comments. Srinivas Nalamachu, MD, clinical assistant
professor, for his vast clinical expertise and helpful suggestions. Kenneth
H. Willer, medical librarian, and Carmen Townsend, librarian specialist,
for their prompt and extraordinary librarian service. My patients, who
have had procedures, you have taught me much and helped me learn and
improve my skills.
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Contents
Preface xiii
Introduction xv
1Head and Neck
1
Migraine 1/3 2
Migraine 2/3 6
Migraine 3/3 8
Facial Hemispasms 10
Blepharospasms 12
Drooling/Sialorrhea 14
Lingual Dystonia 16
Oromandibular Dystonia 18
Cervical DystoniaTorticollis 1/2 20
Cervical DystoniaTorticollis 2/2 22
Cervical DystoniaRetrocollis 24 Cervical DystoniaLaterocollis 26
Cervical DystoniaAnterocollis 28
2Spasticity/Dystonia: Upper Extremities 31
Adducted/Internally Rotated Shoulder 1/2 32
Adducted/Internally Rotated Shoulder 2/2 34
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Flexed Elbow 36
Pronated Forearm 38
Flexed Wrist 40
Extended Wrist 42
Clenched Fist 44
Thumb-in-Palm 46
Adducted Thumb 48
Intrinsic Plus Hand 50
Extended Digits 52
Writers Cramp 1/3 54
Writers Cramp 2/3 56
Writers Cramp 3/3 58
Safety Information Update 60
Pediatric Dosing for Upper Extremities 61
3Spasticity/Dystonia: Lower Extremities 63
Flexed Hip 1/2 64
Flexed Hip 2/2 66
Adducted Thigh 68
Flexed Knee 70
Extended (Stiff) Knee 72
Equinovarus Foot 1/3 74
Equinovarus Foot 2/3 76
Equinovarus Foot 3/3 78
Valgus Foot 1/2 80 Valgus Foot 2/2 82
Striatal Toe 84
Flexed Toes 86
Safety Information Update 88
Pediatric Dosing for Lower Extremities 89
4Pain Syndromes 91
Cervicothoracic/Myofascial Pain 92
Lumbosacral/Myofascial Pain 94
Thoracic Outlet Syndrome 96
Piriformis Syndrome 98
x CONTENTS
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Neuropathic Cutaneous Pain 100
Lateral Epicondylitis 102
5Hyperhidrosis 105
Forehead/Scalp 106
Axillae 108
Palms 110
Residual Limb 112
Feet 114
Nerve BlocksHands 116
Nerve BlocksFeet 118
6Billing and Reimbursement 121
CPT Codes 122
Guidance Codes 122
Modifiers 123
HCPCS Codes 124
Insurance Coverage of Drugs and Procedures 125
Web Sites for Local CoverageDetermination (LCD) by Medicare 126
Resources for Coding and Billing 126
ICD-9-CM Codes 127
BTX-A and BTX-B Interchangeability 128
Secondary ICD-9-CM Codes 129
7Billing Codes for Specific Conditions
131
Migraine 132
Blepharospasm/Facial Hemispasms 133
Drooling/Sialorrhea 134
Lingual Dystonia 135
Oromandibular Dystonia 136
Cervical Dystonia 137
Spasticity and Other Dystonias 138
Pain 140
Thoracic Outlet Syndrome 142
Hyperhidrosis 143
Nerve Blocks 144
CONTENTS xi
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Example of Financial Waiver 145
Charges for Botulinum Toxin Procedures 146
Body Areas and Related ICD-9-CM Codes 148
8Scales 151
Cervical DystoniaTWSTRS Scale 152
Hyperhidrosis Disease Severity Scale (HDSS) 154
Drooling Impact Score (DIS) 155
Questionnaire-based Scoring System forDrooling Severity and Frequency 156
Drooling Rating Scale 157
The Ashworth Scale 158
The Tardieu Scale 159
Spasm Frequency Score 161
Degree of Adductor Tone 162
Hygiene Score 162
9Clinical Data Forms 163
Neurotoxin Clinic Evaluation andTreatment for Migraine 164
Neurotoxin Clinic Evaluation andTreatment for Facial Spasms 165
Neurotoxin Clinic Evaluation andTreatment for Cervical Dystonia 166
Neurotoxin Clinic Evaluation andTreatment for Spasticity (Upper Extremities) 167
Neurotoxin Clinic Evaluation andTreatment for Spasticity (Lower Extremities) 168
Index 169
CONTENTS xii
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xiii
Preface
In any field of medicine, the quality of care is proportional to the knowledge
of the physician. For the clinician the real challenge is to stay abreast of
new developments in clinical treatments and drug therapies. New indica-
tions for drug therapies are continually emerging. The first indication for
treatment with botulinum toxin was approved by the US Food and Drug
Administration (FDA) in 1989. Currently, there are six FDA-approved
indications (hemifacial spasm, 1989; blepharospasm, 1989; strabismus,
1989; cervical dystonia, 2000; glabellar lines, 2002; and hyperhidrosis,
2004). In addition, there has been a wide-spread growth of applications
beyond the FDA-approved indications for botulinum toxin. The toxin
is used to treat numerous conditions across many specialties. Therefore,
most of the current uses and about half of the applications in this manual
are off-label, and thus should be applied with caution.
This handbook is designed to be a practical introductory and reference
guide for the busy clinician and newcomers to the field of neurotoxin
applications. To facilitate easy clinical use of this handbook the dosing
range tables and related illustrations appear are on facing pages. For some
conditions, however, the anatomic illustrations required multiple pages ofdisplay (migraine, cervical dystonia-torticollis, adducted/internally rotated
shoulder, writers cramp, flexed hip, equinovarus foot, and valgus foot).
In these cases, the dosing tables for the illustrations are repeated on the
facing pages.
The information contained in this book is no substitute for appro-
priate clinical training, knowledge of the anatomy, familiarization with
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xv
Introduction
Muscle Overactivity
Botulinum Toxin
Properties of Botulinum Toxin Preparations
Comparison of Type A and Type B Units FDA-Approved Indications
Botulinum Toxin Dosing
Frequency of Injection
BTX-A Contacts BTX-B Contacts
BTX Resources
Safety Information
BTX-A Dilutions BTX-B Dilutions
Guidance Technique for Injection
Techniques to Minimize Injection Pain
Dilutions
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Muscle Overactivity1
Spasticity Velocity dependentincreased muscle contractionwith stretching. The resistance to movement is
increased with increased velocity of motion. Also,the EMG activity is increased with joint move-
ment and muscle stretching. See the AshworthScale on page 158.
Spastic
dystonia
Active muscle contraction at rest without joint
or limb movement.2The EMG shows continuedmuscle activity at rest. Also, stretch-sensitive andincreased EMG activity with muscle stretching.
Spastic
cocontractionCocontraction of the antagonist muscle with
voluntary muscle contraction of the agonist, andwithout stretching of the antagonist. Also, stretch-sensitive and increased EMG activity with muscle
stretching.
Dystonia Involuntary muscle contractions frequentlycausing twisting and repetitive movements orabnormal postures.3The muscle activity is often
increased with voluntary movements or whenopposing the dystonia. The muscle activitymay involve both the agonist and antagonist
(cocontraction). The EMG may show rhythmicor sustained muscle activity that is increased in
the antagonist with attempted contraction of theagonist.
Focal dystoniaincludes: Blepharospasm Cervical dystonia Oromandibular Writers cramp
dystonia Spasmodic Torticollis dysphonia
See the TWSTRS scale for cervical dystonia on page 152153.
References
1. Gracies JM. Pathophysiology of spastic paresis. II: emergence of muscle
overactivity. Muscle Nerve2005;31:55271.
2. Denny-Brown D. The Cerebral Control of Movement. Liverpool: Liverpool
University Press, 1966;12443, 17184.
3. Rowland LP. Merritts Textbook of Neurology, 8th ed. Philadelphia:
Lea & Febiger, 1989.
xvi INTRODUCTION
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Botulinum Toxin
Botulinum toxinsare produced by the bacterium Clostridium botulinum.It is a gram-positive and spore-forming obligate anaerobic bacteria found
in the soil.
Seven serotypes exist (types A, B, C1, D, E, F and G),and two arecommercially available for clinical use in the United States, namely type A
(Botox, Allergan, Inc.) and type B (Myobloc, Solstice Neurosciences,Inc.). At this writing, another type A (Dysport, Ipsen Ltd., U.K.) is notavailable in the United States.
Mechanism of action. Botulinum toxin inhibits the release ofneurotransmitters such as acetylcholine by entering the presynaptic
neurons and cleaving proteins responsible for docking and fusion of thesynaptic vesicles to the presynaptic membrane. Type B acts on the outsideof the synaptic vesicle, cleaving the vesicle-associated membrane protein
(VAMP, synaptobrevin), whereas type A acts on the inner surface of
the postsynaptic membrane (synaptosomal-associated protein of 25kd,SNAP-25). In addition to inhibiting acetylcholine release, botulinum
toxin also appears to inhibit the release of other neurotransmitters suchas noradrenaline, dopamine, gamma-aminobutyrate, glycine, peptide
methionine-enkephalin, as well as the pain nociceptor substance P.1,2
In the muscle,botulinum toxin inhibits the release of acetylcholineat the neuromuscular junction of the muscle fibers (extrafusal fibers) and
at the muscle spindles (intrafusal fibers). The reduced activation of themuscle spindles may contribute to muscle relaxation. In the periphery,botulinum toxin may reduce the release of pain nociceptors.
Mouse unit.Biologic activity is measured in mouse units(medianlethal dose LD
50). One unit (U) is the median lethal intraperitoneal dose
for female Swiss Webster mice weighing 18 to 20 g.
References1. MacKenzie I, Burnstockk G, Dolly JO. The effects of purified botulinum
toxin type A on cholinergic, adrenergic and non-adrenergic atropine-resistant
autonomic neuromuscular transmission. Neuroscience1982;7:9971006.
2. Ishikawa H, Mitsui Y, Yoshitomi T, et al. Presynaptic effects of botulinum
toxin type A on the neuronally evoked response of albino and pigmented
rabbit iris sphincter and dilator muscles.Jpn J Ohpthalmol2000;44:10609.
INTRODUCTION xvii
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xviii INTRODUCTION
Properties of Botulinum Toxin Preparations1,2
BTX-A (Botox) BTX-B (Myobloc)Vials 100 U 2,500 U, 5,000 U, 10,000 U
Albumin 0.5 mg 0.05%
Toxin 5 ng 25 ng, 50 ng, 100 ng
pH 7.3 after constitution 5.6
Storage 24 months refrigerated(Note expiration date) 30 months refrigeration9 months room temp3
(Note expiration date)
Vials Single use Single use
Use within 4 hours of dilution no preservatives
References
1. Mayer NH, Simpson DM, eds. Spasticity: etiology, evaluation, management,and the role of botulinum toxin. We Move, Sept 2002.
2. Package insert for Botox and Myobloc.
3. Royal MA. Botulinum toxins in pain management. Phys Med Rehabil
Clin N Am14(2003):805820.
Comparison of Type A and Type B UnitsUnits of biologic activity of botulinum toxins type A and B cannot be
compared to or converted into units of any other botulinum toxin.
FDA-Approved Indications
BTX-A (Botox) BTX-B (Myobloc)
Hemifacial spasm, 1989
Blepharospasm, 1989
Strabismus, 1989
Cervical dystonia, 2000 Cervical dystonia, 2000
Glabellar lines, 2002
Hyperhidrosis, 2004
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INTRODUCTION xix
Botulinum Toxin Dosing
The dose should be influenced by the patients size, musclehypertrophy, degree of activation by EMG, types of movement,weakness, risk of side effects, potential loss of function, total dose,
diagnosis and responses to prior injections.
Frequency of Injection
Generally, the duration of benefit last for 3-6 months. Thelikelihood of antibody formation appears related to the dose andfrequency of injections. Therefore, extending the time between
injections and using the lowest dose for symptom management maybe desirable. However, the recurrence of symptoms and insurancecoverage may be the ultimate determining factors.
BTX-A Contacts
Allergan for practitioners
Botox information line
1-800-433-8871
1-800-44-Botoxhttp://www.allergan.com/
http://www.botox.com/
BTX-B Contacts
Solstice Neurosciences
Myobloc information
1-888-461-2255
http://www.solsticeneuro.com/
BTX Resources
The NeurotoxinInstitute
We Move
MDVU MovementDisorder VirtualUniversity
http://www.neurotoxininstitute.com/
Independent source of information relatedto the basic science and the clinical
applications of neurotoxin therapies
Free CME materialhttp://www.wemove.org/Worldwide Education and Awareness for
Movement Disorders
http://www.mdvu.org/
Movement Disorder Virtual Universitydosing guidelines
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xx INTRODUCTION
Safety Information
The listed dose suggestions have been obtained from the literatureand the Internet web sites for Allergan, Solstice Neuroscience, MDVUand We Move. Some of the dose recommendations have been made
by consensus panels of clinical experts, such as those published byWe Move and MDVU. Other doses have been obtained from the lit-
erature, while, some of the listed doses have only been found in casestudies. Consequently, the injector should err on the side of safetywhen starting injections in a particular patient. The listed doses do
not guarantee the absence of any untoward effects, because inherentadverse events are associated with all drugs and their administration.The starting dose should be individualized according to the patients
size, weight, weakness, degree of spasticity, potential for functionallosses, and degree of dysfunction. The treating physician is encour-
aged to review the literature for specific dosing.
Contraindications Botulinum toxin treatment is contraindicated in
the presence of infection at the injection site(s)and in individuals with known hypersensitivityto any ingredient in the formulation.
Warnings Serious and/or immediate hypersensitivity reac-tions have been rarely reported. These reactions
include anaphylaxis, urticaria, soft-tissue edema,and dyspnea. If such a reaction occurs, further
injection should be discontinued and appropriatemedical therapy immediately instituted. Patientswith peripheral motor neuropathic diseases (e.g.,
amyotrophic lateral sclerosis or motor neuropa-thy) or neuromuscular junctional disorders (e.g.,myasthenia gravis or Lambert-Eaton syndrome)
should only receive treatment with caution. Pa-tients with neuromuscular disorders may be at
increased risk of clinically significant systemiceffects, including severe dysphagia and respira-tory compromise from typical botulinum toxin
doses. Treatment of botulinum toxinnave pa-tients should be initiated at lower doses. Cautionshould be given to injection of nursing women
and only to pregnant women if clearly needed.
Adverse events There have been rare reports of adverse eventsinvolving the cardiovascular system, including
arrhythmia and myocardial infarction, somewith fatal outcomes.
ReferencePackage insert for Botox and Myobloc.
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INTRODUCTION xxi
BTX-B Safety Information
Botulinumtoxin type B
Myobloc
The initial dose of Myobloc for patients witha prior history of tolerating botulinum toxininjections is 2,500 to 5,000 U divided among
affected muscles. Patients withouta prior historyof tolerating botulinum toxin injections should
receive a lower initial dose.1
Reference
1. Myobloc product information.
Safety Information Update
At the time of this writing the U.S. Food & Drug Administration (FDA)has issued an early communication about an ongoing safety reviewof botulinum toxins type A and B. The FDA has received reports of
systemic adverse reactions including respiratory compromise and deathfollowing the use of botulinum toxins types A and B for both FDA-
approved and unapproved uses. The reactions reported are suggestiveof botulism, which occurs when botulinum toxin spreads in the bodybeyond the site where it was injected. The most serious cases had out-
comes that included hospitalization and death, and occurred mostlyin children treated for cerebral palsy-associated limb spasticity. Useof botulinum toxins for treatment of limb spasticity (severe arm and
leg muscle spasms) in children or adults is not an approved use in theUnited States.
The pediatric botulism cases occurred in patients less than 16 yearsold, with reported symptoms ranging from dysphagia to respiratoryinsufficiency requiring gastric feeding tubes and ventilatory support.
Serious outcomes included hospitalization and death. The mostcommonly reported use of botulinum toxin among these cases was
treatment of limb muscle spasticity associated with cerebral palsy. ForBotox, doses ranged from 6.25 to 32 Units/kilogram (U/kg) in thesecases. For Myobloc, reported doses were from 388 to 625 U/kg.
FDA is aware of the body of literature describing the use ofbotulinum toxins to treat limb spasticity in children and adults.The safety, efficacy and dosage of botulinum toxins have not been
established for the treatment of limb spasticity of cerebral palsy orfor use in any condition in children less than 12 years of age.
The reports of adult botulism cases described symptoms includingpatients experiencing difficulty holding up their heads, dysphagia andptosis. Some reports described systemic effects that occurred distant
from the site of injection and included weakness and numbness ofthe lower extremities. Among the adult cases that were serious,
including hospitalization, none required intubation or ventilatorysupport. No deaths were reported. The doses for Botox ranged from100 to 700 Units and for Myobloc from 10,000 to 20,000 U.
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xxii INTRODUCTION
Safety Information (continued)
Until such time that FDA has completed its review, healthcareprofessionals who use medicinal botulinum toxins should: Understand that potency determinations expressed in Units
or U are different among the botulinum toxin products;clinical doses expressed in units are not comparable from one
botulinum product to the next Be alert to the potential for systemic effects following admin-
istration of botulinum toxins such as: dysphagia, dysphonia,
weakness, dyspnea or respiratory distress Understand that these effects have been reported as early as one
day and as late as several weeks after treatment Provide patients and caregivers with the information they need
to be able to identify the signs and symptoms of systemic effects
after receiving an injection of a botulinum toxin Tell patients they should receive immediate medical attention
if they have worsening or unexpected difficulty swallowing or
talking, trouble breathing, or muscle weakness
From: FDA, Early Communication, February 8, 2008.
http://www.fda.gov/cder/drug/early_comm/botulinium_toxins.htm
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INTRODUCTION xxiii
BTX-A Dilutions
Dilution with preservative-free saline.
100 U/syringe10 U/0.1 cc
100 U1 cc
50 U/syringe5 U/0.1 cc
100 U2 cc
100 U/syringe25 U/1 cc
100 U
4 cc
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xxiv INTRODUCTION
BTX-B Dilutions
Myobloc may be diluted with normal saline.
2,500 U/ 0.5 cc500 U/0.1 cc
2,500 U/0.5 cc 0.5 cc
5,000 U/1 cc500 U/0.1 cc
5,000 U/1 cc1 cc
5,000 U/1 cc
500 U/0.1 cc
10,000 U/2 cc 1 cc
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INTRODUCTION xxv
Guidance Techniquefor Injection of Botulinum Toxin
Electricalstimulation
Particularly useful for dynamic muscle overactivity,where the EMG activity is only present when reflexesare elicited. This may be the case for an upgoing
hallux or toe curling seen only during stance or gait.In such cases, the EMG activity may be too difficult
to elicit at rest. Electrical stimulation may be theonly way to localize the muscles.
Also useful to target smaller muscle groups in theforearm, while avoiding weakening of nearby usefulmuscles. Not useful with strongly contracting muscle
groups in which the electrical stimulation may nothave any effect on limb movement.
Can be used to localize motor points (area of smallmotor nerve endings in the muscle and often close to
the motor endplate zone).1This requires full musclerelaxation. The needle is directed to the part of themuscle where a contraction can be elicited with
stimulation of only 1 mAmp or less.
NeedleEMG
First palpate for the overactive muscle during rangeof motion of the involved joint.
Then, after needle insertion, target the area of themost EMG activity and place the needle so that themotor unit produces a crisp sound. This assures
placement closest to the most active motor units.Placement of the needle at the midbelly of the musclevs. close to the motor endplate (neuromuscular junc-
tion) or motor point has not clearly shown any func-tional benefits.1,2The majority of motor endplates
will be found within the greatest bulk of the muscle.3
Passive stretch of the involved muscle will elicitincreased EMG activity, which can be used to guide
the injection as well. Again, inject into the area withthe most EMG activity elicited and with the crispest
sound.
Needle EMG can also be used to identify motor
endplates. However, this requires the patient to beable to relax the muscles completely. The charac-teristic features of the endplate are: a low-voltage
increase in the baseline of about 10 to 40 mV,irregularly firing monophasic spike discharges,
and deep pain described by the patient.1
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xxvi INTRODUCTION
Guidance Techniquefor Injection of Botulinum Toxin (Continued)
Audio-onlyEMG
Audio only and no EMG display. This may causethe injector to mistake the sound of muscle denerva-tion potentials for muscle motor units. Recommend
the user first becomes familiar with the combinedaudio and visual display of EMG activity (denerva-
tion potentials and motor unit activity), before usingaudio-only EMG. Also, Medicare may not cover the
monitoring unless both visual and auditory compo-nents are procured.
References1. Childers MD. The importance of electromyographic guidance and electrical
stimulation for injection of botulinum toxin. Phys Med Rehabil Clin N Am
2003;14:78192.
2. Satila H, Iisalo T, Pietikainen T, et al. Botulinum toxin treatment of spasticequinus in cerebral palsy. Am J Phys Med Rehabil2005;84:35565.
3. Childers MK. Targeting the neuromuscular junction in skeletal muscles.
Am J Phys Med Rehabil2004;83(Suppl);S38S44.
Techniques to Minimize Injection Pain
Topical Spray with an evaporant such as ethyl chlo-
ride or Flouri-Methane.Topical anesthetic such as lidocaine/
prilocaine in the form of a gel or
transdermal patch.
Oral Medications Premedication with opioids or anxiolytics.
Dilution withpreservative1
Botulinum toxin type B: further dilution withpreserved saline.
Dilution withanesthetic2
With a pH of 5.6, the Myobloc preparationmay cause local injection discomfort. There-
fore, recommendations have been made todilute the BTX preparation with preservedsaline, lidocaine, or bupivacaine to provide a
local anesthetic effect.
Nerve blocksSee pages 116118.
References
1. van Laborde, S, Dover JS, Moore M, et al. Reduction in injection pain
with botulinum toxin type B further diluted using saline with preservative:
a double-blind, randomized controlled trial.J Am Acad Dermatol
2003;489(6):87577.
2. Royal MA. The use of botulinum toxin in the management of myofascial
pain and other conditions associated with painful muscle spasm. In: Brin
MF, Jankovic J, Hallet M, eds. Scientific and Therapeutic Aspects ofBotulinum Toxin. Philadelphia: Lippincott Williams & Wilkins, 2002.
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INTRODUCTION xxvii
Dilutions
BTX-A (Botox) BTX-B (Myobloc)*
100 U/1 cc = 100 U/cc100 U/2 cc = 50 U/cc
100 U/4 cc = 25 U/cc
Undiluted = 250 U/0.05 cc
2,500 U + 1 cc NS= 83 U/0.05 cc
5,000 U + 1 cc NS= 125 U/0.05 cc
2,500 U + 2 cc NS
= 50 U/0.05 cc
5,000 U + 2 cc NS
= 83 U/0.05 cc
*Each vial has an overfill amount beyond what is noted on the label.Therefore, do not perform dilutions in the vial. Pull out the desired volume
in a syringe and add the desired additional volume of saline.
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1
CHAPTER1Head and Neck
Migraine
Facial Hemispasms
Blepharospasms
Drooling/Sialorrhea
Lingal Dystonia
Oromandibular Dystonia
Cervical Dysontia
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Migraine 1/3 Dosing Ranges
Botox(BTX-A)units1,2
Myobloc(BTX-B)units3
Injectionsites permuscle
Procerus 2.55.0/site 50100
(125500)*1
Corrugator, medial 2.54.0/site Limited data 1
Frontalis 2.5/site(46/side)
5007505001,2504,8
812
Temporalis(each muscle)
2.55/site
(4/side)
Limited data for
specific musclesSee data for
regions belowreference 3
4
Occipitalis 510/side 1
Splenius capitis 515/side 12
Masseter 515/side 12
Levator scapulae 1025/side6,7
Trapezius 515/side 6251,000/side4,5,8 13
Semispinalis 510/side Limited data forspecific muscles
1
Sternocleidomastoid 1020/side 2
Total dose 100200 2,5005,000
Dilution 100 U/24 ccDispensed in
1 cc syringes
Dilutions,see page xxvii.
Needle 30 G, 0.5 in
Facial injections are done bilaterally to avoid asymmetric expressions.
* Data for facial hemispasms.
Author recommendation.
3. Inadequate data for specific muscles. Dose ranges for areas3,4:
Lateral neck muscles 625 U/sideCervical paraspinals 500650 U/sideOccipital 500625/side
Temporal 250/side
6,7. Doses used for trigger points/tender points.5,6
Injection Technique (see page 5)
References (see page 4).
Safety information (see pages xxxxii).
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MIGRAINE 1/3 3
Muscles possibly involved Migraine 1/3Procerus
CorrugatorFrontalisTemporalisOccipitalisSplenius capitisMasseterLevator scapulaeTrapeziusSternocleidomastoid
Cervical paraspinal muscles
Authors technique
Orbicularisoculi
Levatorlabii superioris
Zygomaticus
Orbicularis oris
Depressoranguli oris
Mentalis
Blumenfeld technique
Procerus
Orbicularis
oculi
Levatorani nasi
Levatoranguli oris
Nasalis
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4 HEAD AND NECK
References
1. Blumenfeld A, Binder W, Silberstein SD, Blitzer A. Procedures for
administering botulinum toxin type A for migraine and tension-typeheadache. Headache2003;43:88491.
2. MDVU. MD Virtual University, We Move. BTX-A Adult Dosing Guidelines.
Management of Spasticity with Botulinum Toxin Type A (Botox).
Edition 2.0. Revised August 2005.
3. Fadeyi MO, Adams QM. Use of botulinum toxin type b for migraine and
tension headaches. Am J Health-Syst Pharm2002;59:186062.
4. Schulte-Mattler WJ, Martinez-Castillo JC. Botulinum toxin therapy of
migraine and tension-type headache: comparing different botulinum toxinpreparations. Eur J Neurol2006;13(Suppl 1):5154.
5. Kamanli A, Kaya A, Ardicoglu O, et al. Comparison of lidocaine injection,
botulinum toxin injection, and dry needling to trigger points in myofascial
pain syndrome. Rheumatol Int2005;25:60411.
6. Graboski CL, Gray DS, Burnham RS. Botulinum toxin a versus bupivacaine
trigger point injections for the treatment of myofascial pain syndrome: a
randomized double blind crossover study. Pain2005;118:17075.
7. Lake AE III, Saper JR. Botulinum toxin type B for migraine prophylaxis:
a 4-month, open-label, prospective outcome study. Poster presented at the
22ndAnnual Scientific Meeting of the American Pain Society, March 2023,
2003, Chicago, IL.
8. Mathew MT, Frishberg M, Gawel M, et al. Botox CDH study group.
Headache2005;45:293307.
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MIGRAINE 1/3 5
Injection Precautions
Bruising Avoid injecting into visible superficial bloodvessels.
For facial injections, place the patient inupright or semiupright position to minimizebleeding and bruising.
Apply pressure and cold packs after theinjection.
Angle needle ~45 degrees.
Depth ofinjection
Intramuscular. Intradermal and periostealinjections are less effective.
Symmetricalinjections
For facial injections, to avoid asymmetricexpression. Consider preinjection photos.
Ptosis Avoid injections into the brow areas. Inject
approximately 2 cm above the brows.Avoid injections above the levator palpebra(see page 1213).
Intravascular
injectionsCan be minimized by applying vacuum to
the syringe before the injection, avoidingvisible superficial vessels and intraperiostealinjections.
Injection Techniques
Follow-the-pain This approach for injections allows a more
individualized approach depending on thepatients localization of pain and tender/trigger points. The dosing may vary from side
to side except for the facial area.
Fixed-siteinjections
Fixed, symmetrical injections are used toinfiltrate the target region. This approachmay not include areas with pain such as the
scalp. On the other hand, this approach mayalso include injections of areas with no pain
or trigger/tender points such as the frontalismuscle. Conceivably, the cosmetic benefits
may influence the patients decision to havefuture treatments regardless of the effects onpain relief.
Combination
approachHere the fixed-site approach is used forcertain areas, while the follow-the-pain
approach is used for other areas.
Modified after Blumenfeld et al.
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Migraine 2/3 Dosing Ranges
Botox(BTX-A)units1,2
Myobloc(BTX-B)units3
Injectionsites permuscle
Procerus 2.55.0/site 50100
(125500)*
1
Corrugator, medial 2.54.0/site Limited data 1
Frontalis 2.5/site
(46/side)
500750
5001,2504,8
812
Temporalis(each muscle)
2.55/site(4/side)
Limited data forspecific muscles
See data for
regions belowreference 3
4
Occipitalis 510/side 1
Splenius capitis 515/side 12
Masseter 515/side 12
Levator scapulae 1025/side6,7
Trapezius 515/side 6251,000/side4,5,8 13
Semispinalis 510/side Limited data forspecific muscles
1
Sternocleidomastoid 1020/side 2
Total dose 100200 2,5005,000
Dilution 100 U/24 cc
Dispensed in1 cc syringes
Dilutions,
see page xxvii
Needle 30 G, 0.5 in
Facial injections are done bilaterally to avoid asymmetric expressions.
* Data for facial hemispasms.
Author recommendation.
3.
Inadequate data for specific muscles. Dose ranges for areas4,5
:Lateral neck muscles 625 U/sideCervical paraspinals 500650 U/sideOccipital 500625/side
Temporal 250/side
6,7. Doses used for trigger points/tender points.6,7
Injection Technique (see page 5)
References (see page 4).
Safety information (see pages xxxxii).
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Muscles possibly involved Migraine 2/3Procerus
CorrugatorFrontalisTemporalisOccipitalisMasseterLevator scapulaeSternocleidomastoidSplenius capitisTrapezius
Cervical paraspinal muscles
Temporalis
Occipitalis
Sternocleidomastoid
Masseter
Levator scapuli
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Migraine 3/3 Dosing Ranges
Botox(BTX-A)units1,2
Myobloc(BTX-B)units3
Injectionsites permuscle
Procerus 2.55.0/site 50100
(125500)*
1
Corrugator, medial 2.54.0/site Limited data 1
Frontalis 2.5/site
(46/side)
500750
5001,2504,8
812
Temporalis
(each muscle)2.55/site(4/side)
Limited data forspecific muscles
See data forregions below
reference 3
4
Occipitalis 510/side 1
Splenius capitis 515/side 12
Masseter 515/side 12
Levator scapulae 1025/side6,7
Trapezius 515/side 6251,000/side4,5,8 13
Semispinalis 510/side Limited data forspecific muscles
1
Sternocleidomastoid 1020/side 13
Total dose 100200 2,5005,000
Dilution 100 U/24 cc
Dispensed in1 cc syringes
Dilutions,
see page xxvii
Needle 30 G, 0.5 in
Facial injections are done bilaterally to avoid asymmetric expressions.
* Data for facial hemispasms
Author recommendation.
3. Inadequate data for specific muscles. Dose ranges for areas4,5:
Lateral neck muscles 625 U/sideCervical paraspinals 500650 U/sideOccipital 500625/side
Temporal 250/side
6,7. Doses used for trigger points/tender points.6,7
Injection Technique (see page 5)
References (see page 4).
Safety information (see pages xxxxii).
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Muscles possibly involved Migraine 3/3Procerus
CorrugatorFrontalisTemporalisOccipitalisMasseterSternocleidomastoidLevator scapulaeSplenius capitisTrapezius
Cervical paraspinal muscles
Trapezius
Splenius capitis
Semispinalis capitis
Occipitalis
Splenius cervicis
Levator scapuli
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Muscles possibly involved Facial HemispasmsProcerus
Orbicularis oculiNasalisLevator ani nasiLevator anguli orisZygomaticus majorOrbicularis orisBuccinatorRisoriusDepressor anguli oris
Depressor labii inferiorisMentalis
Orbicularis
oculi
Orbicularisoculi
Zygomaticus
Orbicularis orisDepressoranguli oris
Mentalis
Levatorani nasi
Levatoranguli oris
Depressorlabii inferioris
Risorius
Procerus
Nasalis
Buccinator
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Blepharospasms Dosing Ranges
Botox
(BTX-A)units1
Myobloc
(BTX-B)units2
Injection
sites permuscle
Orbicularis oculi
Pretarsal fibers512.5/site
2501,000 25
Procerus 2.552.57/site
250500 1/side
Frontalis 10
2.57.5/site
500750
5001,250*
2/side
Corrugator 5
37.5/site
250750 1/side
Total dose 12.515 7502,500U/side
Dilution 100 U/24 cc
Dispensed in1 cc syringes
Dilutions,
see page xxvii
Needle 30 G, 0.5 in
*Dose from migraine chart.1
Author recommendation.
Injection Technique
See additional
informationunder migrainepage 5.
Injection sites will vary according the muscleactivity.
Injections of the orbicularis oculare are donemedial and lateral to the levator palpebrae to
avoid ptosis.
Avoiding injecting the central part of thelower lid helps prevent entropion and sagging
of the lower lid.3
Injections too deeply into the medial lowereyelid may cause diffusion into the inferioroblique muscle with a potential for diplopia.4
References
1. MDVU. MD Virtual University. Adult Dosing Guidelines. Management
of Dystonia with Botulinum Toxin Type A (Botox). Edition 2.0. Revised
August 2005.
2. MDVU. MD Virtual University. BTX-B Adult Dosing Guidelines. Edition
1.0. Botulinum Toxin Type B (Myobloc). At http://www.mdvu.org/library/
dosingtables/btxb_adg.html. Updated 1.28.05. Accessed 11.30.06.
3. Bhidayasiri R, Cardoso F, Truong DD. Botulinum toxin in blepharospasm
and oromandibular dystonia: comparing different botulinum toxin
preparations. Eur J Neurol2006;13(Suppl 1):2129.
4. Campos EC, Bolzani R, Schiavi C, et al. Effect of injection sites of
botulinum toxin for blepharospasm treatment: statistical analysis.Neuro-ophthalmol1999;22:1723.
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Muscles possibly involved BlepharospasmsOrbicularis oculiProcerus
FrontalisCorrugator
Orbicularis oculi
Levator palpebrae
Orbicularisoculi
Orbicularisoculi
Orbicularisoculi
Corrugator
Levatorani nasi
Levator
anguli oris
Procerus
Nasalis
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Drooling/Sialorrhea Dosing Ranges
Botox(BTX-A)units1
Myobloc(BTX-B)units2
Injectionsites pergland
Parotid glands 1540/gland 5001,000/
gland*1,000/gland
2
Submandibular
glands +/ ultrasoundguidance
1015/gland 250/gland 1
Dilution 100 U/12 ccDispensed in1 cc syringes
Dilutions,see page xxvii
Needle 30 G, 0.5 in
Injection Technique
Parotid Posterior to the palpated masseter muscle andanterior to the external ear2
Submandibular Anterior and medial to the genu of the mandible2
* Author recommendation.
References
1. Porta M, Gamba M, Bertacchi G, Vaj P. Treatment of sialorrhea with
ultrasound guided botulinum toxin type A injection in patients with
neurological disorders.J Neurol Neurosurg Psychiatry2001;70:53840.
2. Ondo WG, Hunter C, Moore W. A double-blind placebo-controlled trial
of botulinum toxin B for sialorrhea in Parkinsons disease. Neurology
2004;62:3740.
See drooling scales pages 155157.
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Glands possibly involved Drooling/SialorrheaParotid glands
Submandibular glandsSublingual glands
Parotid
Submandibular
Sublingual
Submandibular
Sublingual
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Lingual Dystonia Dosing Ranges
Botox(BTX-A) units1,2 Myobloc(BTX-B) units Injection sitesper muscle
Genioglossusmuscle
10301,2 5001,0004 12/side
Hypoglossus 1030 Limited data* 1
Total dose 1030
Dilution 100 U/12 cc
Dispensed in1 cc syringes
Dilutions,
see page xxvii
EMG needle 2725 G, 1 in
*Inadequate data for dose recommendations.
Injection Technique
Intraoral Genioglossus. 1520 U/side injected at two sites atthe base of the tongue, using 27G, 1 in needle.3
Intrinsic muscles. 1520 U/side in two locations,middle lateral side of tongue, using 30 G,1/2 in needle.3
Submandibular
approachGenioglossus. 515 U/side injected at two sitesbilaterally through a percutaneous submandibular
approach,1using a 2725 G EMG needle.
Other
Adverse events Dysphagia, dysarthria
Tongue protrusion Due to the action of the posterior fibers of thegenioglossus5
Tongue retraction Due to the action of the anterior fibers5
References
1. Charles PD, Davis T, Shannon KM, Hook MA, Warner JS. Tongue
protrusion dystonia: treatment with botulinum toxin. 1997;90:52225.
2. MDVU. MD Virtual University. We Move. Adult Dosing Guidelines.
Management of Dystonia with Botulinum Toxin Type A (Botox).
Edition 2.0. Revised August 2005.
3. Clark TG. The management of oromandibular motor disorders and facial
spasms with injections of botulinum toxin. Phys Med Rehabil Clin N Am
2003;14:72748.
4. MDVU. MD Virtual University. BTX-B Adult Dosing Guidelines
Edition 1.0. Botulinum Toxin Type B (Myobloc). At http://www.mdvu.org/
library/dosingtables/btxb_adg.html. Updated 1.28.05. Accessed 11.30.06.
5. Bhidayasiri R, Cardoso F, Truong DD. Botulinum toxin in blepharospasm
and oromandibular dystonia: comparing different botulinum toxin
preparations. Eur J Neurol2006;13(Suppl 1):2129.
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Digastric Mylohyoid
Genioglossus muscle
Geniohyoid muscle
Mylohyoid muscle
Muscle possibly involved Lingual DystoniaGenioglossus muscle
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Oromandibular Dystonia Dosing Ranges
Botox
(BTX-A) units2
Myobloc
(BTX-B) units3
Injection
sitesMasseter 40/side (25100) 1,0003,000 2/side
Temporalis 40/side (2060) 5001500
1,0003,00024/side
Orbicularis oris 1520*4/side 250500 24/side
Anterior digastric,geniohyoid,
mylohyoid
10 (10200) 250750 1/side
Medial pterygoid 15 (1550) 1,0003,000 1/side
Lateral pterygoid 40 (20100) 1,0003,000 1/side
Total dose 1,2505,000 U
per side
Dilution 100 U/12 cc
Dispensed in1 cc syringes
Dilutions,
see page xxvii
Needle 30 G, 0.5 in to 27 G, 37 mm
*Inject below the lower lip in four locations. Only inject in the upperlip if this approach does not work fully.4 Author recommendation. May lower dose with bilateral multiplemasticatory muscle injections.
Injection Technique
Medianpterygoid
Can be approached either intraorally or from below.1From below: The needle is inserted 0.5 to 1 cm anteriorto the angle of the mandible along the interior aspect of
the mandible and angled perpendicular to the mandibleuntil it can be verified by EMG with the patient clenching
his teeth. Oral approach: Posterior to the lower molars.The facial artery lies anteriorly. A bite bloc placed later-ally can be helpful to prevent trauma to the fingers.
Lateralpterygoid
Laterally, the entry point is approximately 35 mm from
the external auditory canal and 10 mm from theinferior margin of the zygomatic arch.1The EMG
needle is angled upward about 15 degrees to reach the
inferior head of the lateral pterygoid.
Other
Mouth opening Lateral pterygoid is the major contributor.
Mouth closure Masseter, medial pterygoid, temporalis.
Adverse events Potential for hypernasal speech due to palatal
muscle weakness, especially with the lateralpterygoid muscle injection.4
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References
1. Bhidayasiri R, Cardoso F, Truong DD. Botulinum toxin in blepharospasm
and oromandibular dystonia: comparing different botulinum toxin
preparations. Eur J Neurol2006;13(Suppl 1):2129.2. MDVU. MD Virtual University. We Move. Adult Dosing Guidelines.
Management of Dystonia with Botulinum Toxin Type A (Botox).
Edition 2.0. Revised August 2005.
3. MDVU. MD Virtual University. BTX-B Adult Dosing Guidelines Edition 1.0.
Botulinum Toxin Type B (Myobloc). At http://www.mdvu.org/library/
dosingtables/btxb_adg.html. Updated 1.28.05. Accessed 11.30.06.
4. Clark GT. The management of oromandibular motor disorders and facial
spasms with injections of botulinum toxin. Phys Med Rehabil Clin N Am2003;14:72748.
Muscles possibly involved Oromandibular DystoniaMasseter
TemporalisOrbicularis orisMedial pterygoidLateral pterygoidDigastricGeniohyoidMylohyoid
Temporalis
Digastric
Lateralpterygoid
Medial pterygoid Masseter
See previous illustrations for the anterior digastric, geniohyoid, and
mylohyoid muscles.
Orbicularis
oris
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Cervical Dystonia Torticollis 1/2 Dosing Ranges
Botox(BTX-A) units1,2 Myobloc(BTX-B) units3 Injection sitesper muscle
Splenius capitis 75 (50150) 1,0005,000 24
Splenius cervicis 30 (2060) Limited data 2
Inferior obliquelongus capitis
304 Limited data
Sternocleidomastoid contralateral
50 (1575) 1,0003,000 14
Levator scapula 50 (25100) 1,0004,000 13
Cervical dystonia 5,00010,000
Dilution 100 U/24 cc
Dispensed in1 cc syringes
Dilutions,
see pagexxvii
EMG needle 27 G, 37 mm
Injection Technique
Splenius capitis Posterior approach: One finger breadth lateralto the C5 spinous process.
Splenius cervicis Posterior approach: Onetwo finger breadths
lateral to the T1 spinous process.Inferior obliquelongus capitis
Lateral approach: Approximately twothree fingerbreadths below the tip of mastoid process at thetop level of the C2 spinous process. Beware of
the location of the vertebral artery and the super-ficial occipital nerve.5The greater occipital n. lies
posterior over the inferior oblique capitis.
Posterior approach: Less than one fingerbreadth lateral to the C2 spinous process.Be aware of the intervertebral space of C1-C2anterior to the inferior oblique longus capitis.
Neck injections pose a significant risk for dysphagia.
References
1. MDVU. MD Virtual University. We Move. Adult Dosing Guidelines.
Management of Dystonia with Botulinum Toxin Type A (Botox).
Edition 2.0. Revised August 2005.
2. Clinical experience helps you determine the lowest effective dose.
BTX 0104. Irvine CA: Allergan Inc., 2002.
3. MDVU. MD Virtual University. BTX-B Adult Dosing Guidelines.
Edition 1.0. Botulinum Toxin Type B (Myobloc). At http://www.mdvu.org/
library/dosingtables/btxb_adg.html. Updated 1.28.05. Accessed 11.30.06.
4. Walker FO. Botulinum toxin therapy for cervical dystonia. Phys Med
Rehabil Clin N Am2003;14:74966.
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Splenius capitis
Semispinalis capitis
Occipitalis
Splenius cervicis
Levator scapuli
Inferior obliquelongus capitis
Muscles possibly involved Cervical Dystonia Ipsilateral splenius capitis Torticollis 1/2
Splenius cervicisInferior oblique longus capitisLevator scapulaeContralateral sternocleidomastoid
CERVICAL DYSTONIA TORTICOLLIS 1/2 21
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Cervical DystoniaTorticollis 2/2 Dosing Ranges
Botox(BTX-A) units1,2 Myobloc(BTX-B) units3 Injectionsites permuscle
Splenius capitis(ipsilateral)
75 (50150) 1,0005,000 24
Splenius cervicis 30 (2060) Limited data 2
Inferior oblique
longus capitis304 Limited data
Sternocleidomastoid
(contralateral)50 (1575) 1,0003,000 14
Levator scapula 50 (25100) 1,0004,000 13
Cervical dystonia 5,00010,000
Dilution 100 U/24 cc
Dispensed in1 cc syringes
Dilutions,
see pagexxvii
EMG needle 27 G, 37 mm
Injection Technique
Sternocleidomastoid(contralateral) The midbelly of the muscle is verticallybelow the angle of the jaw.
Levator scapula Lateral approach:is at the level of thethyroid cartilage and one finger breadth,
anterior to the trapezius and posterior tothe vertical line of the styloid process.
Posterior approach:is approximately three
finger breadths lateral to the C6 sponoursprocess.
Neck injections pose a significant risk for dysphagia.
References
1. MDVU. MD Virtual University. We Move. Adult Dosing Guidelines.
Management of Dystonia with Botulinum Toxin Type A (Botox).
Edition 2.0. Revised August 2005.
2. Clinical experience helps you determine the lowest effective dose.
BTX 0104. Irvine CA: Allergan Inc., 2002.
3. MDVU. MD Virtual University. We Move. BTX-B Adult Dosing Guidelines.
Edition 1.0. Botulinum Toxin Type B (Myobloc). At http://www.mdvu.org/
library/dosingtables/btxb_adg.html. Updated 1.28.05. Accessed 11.30.06.
4. Walker FO. Botulinum toxin therapy for cervical dystonia. Phys Med
Rehabil Clin N Am2003;14:74966.
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Muscles possibly involved Cervical Dystonia
Ipsilateral splenius capitis Torticollis 2/2
Splenius cervicisInferior oblique longus capitisLevator scapulaeContralateral sternocleidomastoid
Sternocleidomastoid
Levatorscapulae
Levatorscapulae
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Cervical DystoniaRetrocollis Dosing Ranges
Botox(BTX-A)units1,2
Myobloc(BTX-B)units3
Injectionsites permuscle
Splenius capitis bilateral
7550150/side
1,0005,000 24
Semispinalis capitis 7550150
1,0005,000 14
Longissimus 75
50150
1,0005,000 14
Dilution 100 U/24 ccDispensed in1 cc syringes
Dilutions,see page xxvii
EMG needle 27 G, 37 mm
For retrocollis, inject bilaterally to avoid tilting of the head.
Author recommends lower doses with bilateral injections.
Injection Technique
Splenius capitis bilateral Posterior approach: One finger breadth
lateral to the C5 spinous process.
Semispinalis capitis One finger breadth lateral to the C3spinous process.
Longissimus Two finger breadths lateral to the C7spinous process.
Neck injections pose a significant risk for dysphagia.
References
1. MDVU. MD Virtual University. We Move. Adult Dosing Guidelines.
Management of Dystonia with Botulinum Toxin Type A (Botox).
Edition 2.0. Revised August 2005.
2. Clinical experience helps you determine the lowest effective dose.
BTX 0104. Irvine CA: Allergan Inc., 2002.
3. MDVU. MD Virtual University. We Move. BTX-B Adult Dosing Guidelines.
Edition 1.0. Botulinum Toxin Type B (Myobloc). At http://www.mdvu.org/
library/dosingtables/btxb_adg.html. Updated 1.28.05. Accessed 11.30.06.
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Muscles possibly involved Cervical DystoniaRetrocollisSplenius capitis
Semispinalis capitisLongissimus
Splenius capitis
Semispinalis capitis
Occipitalis
Splenius cervicisLevator scapuli
Semispinalis capitis Longissimus
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26 HEAD AND NECK
Cervical DystoniaLaterocollis Dosing Ranges
Botox
(BTX-A) units1,2
Myobloc
(BTX-B) units3
Injection
sites permuscle
Splenius capitis 75
50150
1,0005,000 24
Scalene complex ipsilateral
351550
1,0003,000 13
Levator
scapulae
50
25100
1,0004,000 13
Longissimus 7550150
1,0005,000 14
Dilution 100 U/2 cc
Dispensed in1 cc syringes
Dilutions,
see pagexxvii
EMG needle 27 G, 37 mm
Injection Technique
Spleniuscapitis
Posterior approach: One finger bredth lateral to the
C5 spinous process.
Scalene
complex ipsilateral
The injector should be familiar with the anatomy,because the phrenic nerve lies on anterolateral
surface of the anterior scalene muscle.
Lateral approach: approximately two finger breadthsabove the clavicle.
The anterior scalene is immediately posterior to theclavicular head of the sternocleidomastoid muscle.
Approach the needle slowly and withdraw if anyradiation of pain. The posterior scalene is immedi-
ately anterior to the anterior border of the trapezius.
Ultrasound or fluoroscopy guidance is helpful.Levator
scapulaeLateral approach:Midpoint from the clavicle to themastoid process and immediately anterior the trapezius.
Posterior approach:is approximately three fingerbreadths lateral to the C7 spinous process.
Longissimus Two finger breadths lateral to the C7 spinous process.
Neck injections pose a significant risk for dysphagia.
References
1. MDVU. MD Virtual University. We Move. Adult Dosing Guidelines.
Management of Dystonia with Botulinum Toxin Type A (Botox).
Edition 2.0. Revised August 2005.
2. Clinical experience helps you determine the lowest effective dose.
BTX 0104. Irvine CA: Allergan Inc., 2002.
3. MDVU. MD Virtual University. We Move. BTX-B Adult Dosing Guidelines.
Edition 1.0. Botulinum Toxin Type B (Myobloc). At http://www.mdvu.org/library/dosingtables/btxb_adg.html. Updated 1.28.05. Accessed 11.30.06.
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Muscles possibly involved Cervical DystoniaLaterocollisSplenius capitis
Scalene complexLevator scapulaeLongissimus
Splenius capitis
Semispinalis capitis
Occipitalis
Splenius cervicisLevator scapuli
Longissimus
Posterior scalene
Middle scalene
Anterior scalene
Levator scapuli
CERVICAL DYSTONIA LATEROCOLLIS 27
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28 HEAD AND NECK
Cervical DystoniaAnterocollis Dosing Ranges
Botox(BTX-A) units1,2 Myobloc(BTX-B) units3 Injection sitesper muscle
Sternocleido-mastoid
(bilateral)
501575
1,0003,000 12
Dilution 100 U/2 cc
Dispensed in
1 cc syringes
Dilutions,
see page
xxviiEMG needle 27 G, 37 mm
The dose should be reduced by 50% if both SCM muscles are injected.
Injection Technique
Sternocleidomastoid The midbelly of the muscle is vertically
below the angle of the jaw.
Neck injections pose a significant risk for dysphagia.
References
1. MDVU. MD Virtual University. We Move. Adult Dosing Guidelines.
Management of Dystonia with Botulinum Toxin Type A (Botox).
Edition 2.0. Revised August 2005.
2. Clinical experience helps you determine the lowest effective dose.BTX 0104. Irvine CA: Allergan Inc., 2002.
3. MDVU. MD Virtual University. We Move. BTX-B Adult Dosing Guidelines.
Edition 1.0. Botulinum Toxin Type B (Myobloc). At http://www.mdvu.org/
library/dosingtables/btxb_adg.html. Updated 1.28.05. Accessed 11.30.06.
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Sternocleidomastoid
Anterior scalene
Middle scalene
Trapezius
Levator scapulae
Muscles possibly involved Cervical Dystonia
Bilateral Anterocollissternocleidomastoid
CERVICAL DYSTONIA ANTEROCOLLIS 29
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31
CHAPTER2Spasticity/Dystonia:Upper Extremities
Adducted/Internally Rotated Shoulder
Flexed Elbow Pronated Forearm
Flexed Wrist
Extended Wrist
Clenched Fist
Thumb-in-Palm
Adducted Thumb
Intrinsic Plus Hand
Extended Digits
Writers Cramp Safety Information Update
Pediatric Dosing for Upper Extremities
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32 SPASTICITY/DYSTONIA: UPPER EXTREMITIES
Adducted/Internally Rotated Shoulder 1/2 Dosing Ranges
Botox(BTX-A)units1
Myobloc(BTX-B)units2
Injectionsites permuscle
Pectoralis complex 100 (50200) 2,5005,000 26
Latissimus dorsi 100 (50200) 2,5005,000 26
Teres major 50 (25100) 1,0003,000 14
Subscapularis 75 (50100) 1,0003,000 12Total dose 5,00015,000
Dilution 100 U/4 ccDispensed in1 cc syringes
Dilutions,see page xxvii
EMG needle 2527 G, 3750 mm
Pediatric dosing see page 61.
Injection Technique
Pectoralismajor
Palpate the anterior axillary fold between thumband fingers and inject the muscle. Use caution withneedle depth when injecting over the chest wall.Inject over the ribs to reduce the potential for
pneumothorax.
Latissimusdorsi
Palpate the posterior axillary fold between thumband fingers and inject the muscle. Potential forpneumothorax exists.
Teres major Palpate the muscle at the top of the posterior axillaryfold and direct the needle towards the acromion.
Subscapularis Medial approach: Place patient prone or sitting withhand on back and close to the shoulder blade to wingthe scapula. Inject laterally toward and under thescapula. Lateral (axillary) approach3: Inject betweenthe posterior axillary fold and the brachial pulse.Direct the needle posteriorly towards the subscapularfossas lateral edge. Potential for pneumothorax exists.
Guidelines1,2
BTX-A BTX-B StartingDose
Total maximum bodydose/visit
400600 10,00015,000
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Muscles possibly involved
Pectoralis major
Teres majorLatissimus dorsiSubscapularis
Adducted/InternallyRotated Shoulder 1/2
References
1. MDVU. MD Virtual University. We Move. BTX-A Adult Dosing Guidelines.
Management of Spasticity with Botulinum Toxin Type A (Botox). Edition 3.0.
Revised August 2005.
2. MDVU. MD Virtual University. We Move. BTX-B Adult Dosing GuidelinesEdition 1.0. Botulinum Toxin Type B (Myobloc). At http://www.mdvu.org/
library/dosingtables/btxb_adg.html. Updated 1.28.05. Accessed 11.30.06.
3. Chiodo A, Goodmurphy C, haig A. Cadaveric study of methods
for subscapularis muscle needle insertion. Am J Phy Med Rehabil
2005;84:662665.
Pectoralis major
ADDUCTED/INTERNALLY ROTATED SHOULDER 1/2 33
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34 SPASTICITY/DYSTONIA: UPPER EXTREMITIES
Adducted/Internally Rotated Shoulder 2/2 Dosing Ranges
Botox(BTX-A)units1
Myobloc(BTX-B)units2
Injectionsites permuscle
Pectoralis complex 100 (50200) 2,5005,000 26
Latissimus dorsi 100 (50200) 2,5005,000 26
Teres major 50 (25100) 1,0003,000 14
Subscapularis 75 (50100) 1,0003,000 12
Total dose 5,00015,000
Dilution 100 U/4 ccDispensed in1 cc syringes
Dilutionssee pagexxvii
EMG needle 27 G, 37 mm
Pediatric dosing see page 61.
Injection Technique
Pectoralis
major
Palpate the anterior axillary fold between thumb andfingers and inject the muscle. Use caution with needledepth when injecting over the chest wall. Inject overthe ribs to reduce the potential for pneumothorax.
Latissimusdorsi
Palpate the posterior axillary fold between thumband fingers and inject the muscle. Potential forpneumothorax exists.
Teres major Palpate the muscle at the top of the posterior axillaryfold and direct the needle towards the acromion.
Subscapularis Medial approach: Place patient prone or sittingwith hand on back and close to the shoulder blade
to wing the scapula. Inject laterally toward andunder the scapula.
Lateral (axillary) approach3: Inject betweenthe posterior axillary fold and the brachialpulse. Direct the needle posteriorly towards thesubscapular fossas lateral edge. Potential forpneumothorax exists.
Guidelines1,2
BTX-A BTX-B StartingDose
Total maximum bodydose/visit
400600 10,00015,000
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References1. MDVU. MD Virtual University. We Move. BTX-A Adult Dosing
Guidelines. Management of Spasticity with Botulinum Toxin Type A
(Botox). Edition 3.0. Revised August 2005.
2. MDVU. MD Virtual University. We Move. BTX-B Adult Dosing Guidelines.
Edition 1.0. Botulinum Toxin Type B (Myobloc). At http://www.mdvu.org/
library/dosingtables/btxb_adg.html. Updated 1.28.05. Accessed 11.30.06.
3. Chiodo A, Goodmurphy C, haig A. Cadaveric study of methods
for subscapularis muscle needle insertion. Am J Phy Med Rehabil2005;84:662665.
Muscles possibly involved
Pectoralis major
Teres majorLatissimus dorsiSubscapularis
Adducted/InternallyRotated Shoulder 2/2
Teresmajor
Trapezius
Subscapularis
Latissimus dorsi
ADDUCTED/INTERNALLY ROTATED SHOULDER 2/2 35
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36 SPASTICITY/DYSTONIA: UPPER EXTREMITIES
Flexed Elbow Dosing Ranges
Botox(BTX-A)units1
Myobloc(BTX-B)units2
Injectionsites permuscle
Brachioradialis 6025100
1,0003,00014
Biceps 8075200
2,5005,00024
Brachialis 5040150
1,0003,00012
Dilution 100 U/4 cc Dilutions,see page xxvii
EMG needle 2527 G, 37 mm
Pediatric dosing see page 61.
Injection Technique
Brachioradialis The midbelly of the muscle is at the level ofthe insertion of the biceps tendon.
Biceps Since the biceps supinates the forearmneurolysis may increase forearm pronation.
Brachialis A lateral approach will avoid the bicepsmuscle and the median and ulnar nervesand vessels. At the level of four fingerbreadths above the lateral epicondyle.
Guidelines1,3
BTX-A BTX-B StartingDose
Total maximum
body dose/visit400600 10,00015,000
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Muscles possibly involved Flexed ElbowBrachioradialis
BicepsBrachialis
Biceps
Brachialis
Brachioradialis
HumerusProfundabrachii artery
Radial nerve
Brachial
arteryMedian nerve
Ulnar nerve
Basilic vein
Biceps
Brachialis
Triceps musclemedial head
Triceps musclelateral head
Triceps musclelong head
FLEXED ELBOW 37
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38 SPASTICITY/DYSTONIA: UPPER EXTREMITIES
Pronated Forearm Dosing Ranges
Botox(BTX-A)units1
Myobloc(BTX-B)units2
Injectionsites permuscle
Pronatorquadratus
251050
1,0002,50012
Pronator teres 40502575
1,0002,50012
Dilution 100 U/4 cc Dilutions,see page xxvii
EMG needle 27 G, 37 mm
Pediatric dosing see page 61.
Injection Technique
Pronator teres Midbelly of the muscle is three fingerbreadths distal to the biceps tendon andone finger breadth medially.
Pronator quadratus Dorsal approach between the radius andthe ulnar at one-quarter the distance fromthe ulnar styloid process to the insertion
of the biceps tendon.
Guidelines1,2
BTX-A BTX-B Starting
Dose
Total maximum body
dose/visit
400600 10,00015,000
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PRONATED FOREARM 39
Pronator teres
Pronator quadratus
Muscles possibly involved Pronated ForearmPronator teres
Pronator quadratus
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40 SPASTICITY/DYSTONIA: UPPER EXTREMITIES
Flexed Wrist Dosing Ranges
Botox(BTX-A)units1
Myobloc(BTX-B)units2
Injectionsites permuscle
Flexor carpi radialis 5025100
1,0003,00012
Flexor carpi ulnaris 4020100
1,0003,00012
Flexor digitorumprofundus 202050* 1,0003,000* 12
Palmaris longus 4020100^
1,0003,000^12
Dilution 100 U/4 cc Dilutions,see page xxvii
EMG needle 27 G, 37 mm
Pediatric dosing see page 61.*Values used for clenched fist/fingers.1,2
^Values used for flexor carpi ulnaris.
Injection Technique
Flexor carpiradialis
Midbelly of the muscle at four finger breadthsbelow the elbow crease. Insert one finger breadth
medial to the distal part of the biceps tendon.Flexor carpi
ulnaris
Midbelly of the muscle at one-third the distancefrom the medial epicondyle to the wrist.
Flexor digitorum
profundus
Midbelly of the muscle at the midpoint of thebiceps tendon and the ulnar styloid process.
Palmaris longus Midbelly of the muscle at four finger breadthsbelow the biceps tendon and one finger breadth
medial to a line between the midwrist and thebiceps tendon.
Guidelines1,2
BTX-A BTX-B Starting Dose
Total maximumbody dose/visit
400600 10,00015,000
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Flexorcarpi ulnaris
Flexorcarpi radialis
Flexor
digitorumprofundus
Palmarislongus
Flexor carpi ulnaris
Flexor digitorum profundus
Flexor carpi radialis
Median nerve
Radial artery
Radial nerve
Cephalic vein
Radius Ulna
Ulnar nerve and artery
Palmaris longus tendon
Flexor digitorum superficialis
Extensor carpi radialislongus and brevis
Extensor digitorum
Extensordigiti minimi
Extensor carpi ulnaris
Muscles possibly involved Flexed WristFlexor carpi radialis
Flexor carpi ulnarisFlexor digitorum profundusPalmaris longus
FLEXED WRIST 41
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42 SPASTICITY/DYSTONIA: UPPER EXTREMITIES
Extended Wrist Dosing Ranges
Botox(BTX-A)units1*
Myobloc(BTX-B)units2*
Injectionsites permuscle
Extensor carpi radialis(longus and brevis)
4020100
1,000300012
Extensor carpi ulnaris 4020100
1,0003,00012
Dilution 100 U/4 cc Dilutions,see page xxvii
EMG needle 27 G, 37 mm
*Values for flexor carpi ulnaris under flexed wrist.2
Injection TechniqueExtensor carpi radialislongus
Midbelly of the muscle located at one-thirdof the distance from the lateral epicondyleto the radial styloid process and over theradius.
Extensor carpi radialis
brevis
Midbelly of the muscle located at one-fourth of the distance from the lateral
epicondyle to the radial styloid process andover the radius.
Extensor carpi ulnaris Midbelly of the muscle located at half thedistance from the lateral epicondyle tothe wrist and over the ulna.
Guidelines1,3
BTX-A BTX-B StartingDose
Total maximumbody dose/visit
400600 10,00015,000
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Muscles possibly involved Extended WristExtensor carpi radialis
longusExtensor carpi radialis
brevisExtensor carpi ulnaris
EXTENDED WRIST 43
Flexor carpi ulnaris
Flexor digitorum profundus
Flexor carpi radialis
Median nerve
Radial artery
Radial nerve
Cephalic vein
Radius Ulna
Ulnar nerve and artery
Palmaris longus tendon
Flexor digitorum superficialis
Extensor carpi radialislongus and brevis
Extensor digitorum
Extensordigiti minimi
Extensor carpi ulnaris
Extensor carpiradialis longus
Extensor carpiradialis brevis
Extensorcarpi ulnaris
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44 SPASTICITY/DYSTONIA: UPPER EXTREMITIES
Clenched Fist Dosing Ranges
Botox(BTX-A)units1*
Myobloc(BTX-B)units2*
Injectionsites permuscle
Flexor digitorum
superficialis (per fascicle)202050
1,0003,0001
Flexor digitorumprofundus (per fascicle)
202050
1,0003,0001
Dilution 100 U/4 cc Dilutions,see page xxvii
EMG needle 27 G, 37 mm
Pediatric dosing see page 61.
Injection Technique
Flexor digitorum
superficialisMidbelly of the muscle at the midpoint fromthe biceps tendon to the wrist and mainly overthe proximal and middle ulna and interosseusmembrane. The median and ulnar nerves liesbetween the FDS and FDP.
Flexor digitorum
profundus
Midbelly of the muscle at the midpoint from
the biceps tendon to the wrist and mainly overthe ulna and interosseus membrane. A medialapproach just above the ulna and below theflexor carpi ulnaris will minimize exposure tothe ulnar nerve.
Guidelines1,2
BTX-A BTX-B StartingDose
Total maximum
body dose/visit
400600 10,00015,000
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Muscles possibly involved Clenched FistFlexor digitorum superficialis
Flexor digitorum profundus
Flexordigitorumprofundus
Flexordigitorumsuperficialis
Flexor carpi ulnaris
Flexor digitorum profundus
Flexor carpi radialis
Median nerve
Radial artery
Radial nerve
Cephalic vein
Radius Ulna
Ulnar nerve and artery
Palmaris longus tendon
Flexor digitorum superficialis
Extensor carpi radialislongus and brevis
Extensor digitorumExtensordigiti minimi
Extensor carpi ulnaris
CLENCHED FIST 45
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46 SPASTICITY/DYSTONIA: UPPER EXTREMITIES
Thumb-in-Palm Dosing Ranges
Botox(BTX-A)units1
Myobloc(BTX-B)units2
Injectionsites permuscle
Flexor pollicis longus 201050
1,0002,50012
Flexor pollicis brevis/
opponens
10530
5001,5001
Adductor pollicis 10530
5002,5001
First dorsal interosseus 2.5 250500* 1
Dilution 100 U/4 cc Dilutions,see page xxvii
EMG needle 27 G, 37 mm
Pediatric dosing see page 61.*Dose from the task-specific dystonia chart.2
*Dose from intrinsic plus hand.1
Injection Technique
Flexor pollicislongus
Midbelly at one-third of the distance fromthe wrist to the biceps tendon over the radius.
Flexor pollicis
brevis/opponens
Midbelly at the midpoint and medial borderof the first metacarpal bone.
Adductor pollicis Midbelly over the middle of the secondmetacarpal bone.
First dorsalinterosseus
Midbelly at the midpoint of radial borderof the second metacarpal bone.
Guidelines1,2
BTX-A BTX-B StartingDose
Total maximum bodydose/visit
400600 10,00015,000
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THUMB-IN-PALM 47
Flexorpollicis longus
Flexorpollicis brevis
First dorsalinterosseus
Adductorpollicis
Opponenspollicis
Abductordigiti minimi
Muscles possibly involved Thumb-in-PalmFlexor pollicis longus
Flexor pollicis brevisAdductor pollicisFirst dorsal interosseusOpponens pollicis
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48 SPASTICITY/DYSTONIA: UPPER EXTREMITIES
Adducted Thumb Dosing Ranges
Botox(BTX-A)units1
Myobloc(BTX-B)units2
Injectionsites permuscle
Adductor pollicis 10530*
5002,500*1
Dilution 100 U/4 cc Dilutions,see page xxvii
EMG needle 27 G, 37 mm
*Dose for thumb-in-palm.3
Injection Technique
Adductor pollicis Midbelly over the middle of the secondmetacarpal bone.
Guidelines1,2
BTX-A BTX-B StartingDose
Total maximumbody dose/visit
400600 10,00015,000
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Muscles possibly involved Adducted ThumbAdductor pollicis
ADDUCTED THUMB 49
Adductorpollicis
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50 SPASTICITY/DYSTONIA: UPPER EXTREMITIES
Intrinsic Plus Hand Dosing Ranges
Botox(BTX-A)Units
Myobloc(BTX-B)units3
Injectionsites permuscle
Lumbricals/interossei
10 (515)/lumbrical1
1,500 4,500/hand
1
Dorsal interosseus 2.5/muscle7.525/m.
group2*
250500/hand* 14
Lumbricals 2.5/ muscle7.520/m.group2*
1
Dilution 100 U/4 cc Dilutions,see page xxvii
EMG needle 27 G, 37 mmPediatric dosing see page 61.*For task-specific dystonia.
Injection Technique
Dorsal interossei/Lumbricals
Midbelly of muscles at the midpoint ofthe metacarpals.
Guidelines1,2
BTX-A BTX-B StartingDose
Total maximum body
dose/visit
400600 10,00015,000
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Muscles possibly involved Intrinsic Plus HandDorsal interossei
Lumbrical
Dorsal interossei
Lumbricals
INTRINSIC PLUS HAND 51
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52 SPASTICITY/DYSTONIA: UPPER EXTREMITIES
Extended Digits Dosing Ranges
Botox(BTX-A)units1
Myobloc(BTX-B)units3
Injectionsites permuscle
Extensor indicisproprius
201050*
1,0002,500* 1
Extensor digitorum
communis
202050
1,0003,000 12
Dilution 100 U/4 cc Dilutions,see page xxvii
EMG needle 27 G, 37 mm
*Dose from flexor pollicis longus in thumb-in-palm section.3 Dose from flexor digitorum superficialis in clenched fist section.3
Injection Technique
Extensor digitorum
communis
Midbelly of the muscle at the midpoint ofthe lateral epicondyle and the wrist over theradius.
Extensor indicisproprius
Midbelly one finger breadth of the muscle onthe radial side of the ulna one finger breadthabove the ulnar styloid process.
Guidelines2,3
BTX-A BTX-B StartingDose
Total maximum body
dose/visit
400600 10,00015,000
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EXTENDED DIGITS 53
Muscles possibly involved Extended DigitsExtensor indicis
propriusExtensor digitorum
communis
Flexor carpi ulnaris
Flexor digitorum profundus
Flexor carpi radialis
Median nerve
Radial artery
Radial nerve
Cephalic vein
Radius Ulna
Ulnar nerve and artery
Palmaris longus tendon
Flexor digitorum superficialis
Extensor carpi radialislongus and brevis
Extensor digitorumExtensordigiti minimi
Extensor carpi ulnaris
Extensordigitorum
Extensorindices
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54 SPASTICITY/DYSTONIA: UPPER EXTREMITIES
Writers Cramp 1/3 Dosing Ranges
Botox(BTX-A)units1
Myobloc(BTX-B)units2
Injectionsites permuscle
Flexor digitorumprofundus
15 (1540) 2501,500 13
Flexor carpi radialis 15 (1550) 5002,500 12
Flexor digitorum
superficialis
15 (1540) 2501,500 13
Flexor carpi ulnaris 15 (1550) 5002,500 12
Pronator teres 10 (1035) 5001,500 12
Pronator quadratus 10 (1035) 5001,500 1
Flexor pollicis longus 10 (525) 1,0002,500 1
Dilution 100 U/4 cc Dilutions,see page xxvii
EMG needle 27 G, 37 mm
Injection Technique
Flexor
digitorumprofundus
Midbelly of the muscle at the midpoint of the biceps
tendon and the ulnar styloid process.
Flexor carpiradialis
Midbelly of the muscle at four finger breadths belowthe elbow crease. Insert one finger breadth medial tothe distal part of the biceps tendon.
Flexor
digitorum
superficialis
Midbelly of the muscle at the midpoint from the bicepstendon to the wrist and mainly over the proximal and
middle ulna and interosseus membrane. The medianand ulnar nerves lie between the FDS and FDP.
Flexor carpiulnaris
Midbelly of the muscle at one-third the distance fromthe medial epicondyle to the wrist.
Pronatorteres
Midbelly of the muscle is three finger breadths distal tothe biceps tendon and one finger breadth medially.
Pronatorquadratus
Dorsal approach between the radius and ulnar atone-quarter the distance from the ulnar styloidprocess to the insertion of the biceps tendon.
Flexorpollicis
longus
Midbelly at one-third of the distance from the wristto the biceps tendon over the radius.
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Guidelines1,2
Dystonia BTX-A BTX-B StartingDose
Total maximum bodydose/visit
300 10,00015,000
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56 SPASTICITY/DYSTONIA: UPPER EXTREMITIES
Writers Cramp 2/3 Dosing Ranges
Botox(BTX-A)units1
Myobloc(BTX-B)units2
Injectionsites permuscle
Extensor digitorum 15 (1030) 5001,500 12
Extensor carpi ulnaris 10 (1040) 5001,500 12
Extensor carpi radialis 10 (1040) 5001,500 12
Extensor pollicis longus 7.5 (1515) 5001,000* 1
Extensor pollicis brevis* 2.5 (2.525)* 250500 1
Extensor indicis proprius 2.5 (2.525) 5001,000 1
Dilution 100 U/4 cc Dilutions,see page xxvii
EMG needle 27 G, 37 mm
*Value used as for extensor indicis.Value used as for extensor indicis.2Value used for dorsal interosseus.2
Injection Technique
Extensor digitorumcommunis
Midbelly of the muscle at the midpoint of thelateral epicondyle and the wrist over the radius.
Extensor carpi
ulnaris
Midbelly of the muscle located at half thedistance from the lateral epicondyle to theulnar styloid process and over the ulna.
Extensor carpi
radialis
Midbelly of the muscle located at one-third ofthe distance from the lateral epicondyle to theradial styloid process and over the radius.
Extensor pollicis
longus
Midbelly of the muscle at one-third to one-half the distance from the wrist to the lateralepicondyle and over the interosseus membrane.
Extensor pollicis
brevis
Midbelly of the muscle three finger breadthsabove the ulnar styloid process and on theulnar side of the radius.
Extensor indicisproprius
Midbelly of the muscle on the radial side ofthe ulna one finger breadth above the ulnarstyloid process.
Guidelines*
Dystonia BTX-A BTX-B Starting Dose
Total maximum bodydose/visit
300 10,00015,000
-
8/10/2019 Botulinum Toxin Injection Guid
89/207
References
1. MDVU. MD Virtual University. We Move. BTX-A Adult Dosing Guidelines.
Management of Spasticity with Botulinum Toxin Type A
(Botox). Edition 2.0. Revised August 2005.
2. MDVU. MD Virtual University. We Move. BTX-B Adult Dosing Guidelines
Edition 1.0. Botulinum Toxin Type B (Myobloc). At http://www.mdvu.org/
library/dosingtables/btxb_adg.html. Updated 1.28.05. Accessed 11.30.06.
Muscles possibly involved Writers Cramp 2/3Flexor digitorum profundus Extensor digitorum
Flexor carpi radialis Extensor carpi ulnarisFlexor digitorum superficialis Extensor pollicis longusFlexor carpi ulnaris Extensor pollicis brevisPronator teres Extensor indicisPronator quadratus Adductor pollicis Opponens pollicisFlexor pollicis longus Abductor digiti minimi Dorsal interosseus
Extensordigitorum
Extensor
carpi ulnarisExtensorindices
Extensor
pollicislongusExtensorpollicisbrevis
Extensor carpiradialis longus
Extensor carpiradialis brevis
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58 SPASTICITY/DYSTONIA: UPPER EXTREMITIES
Writers Cramp 3/3 Dosing Ranges
Botox(BTX-A)units1
Myobloc(BTX-B)units2
Injectionsites permuscle
Adductor pollicis 5 (525) 5001,500 1
Abductor digiti minimi 5 (2.525) 125250 1
Opponens pollicis 5 (535) 125250 1
Dorsal interosseus 2.5/ muscle7.525/ musclegroup
250500 1
Dilution 100 U/4 cc Dilutions, seepage xxvii
EMG needle 27 G, 37 mm
Injection Technique
Adductor pollicis Midbelly over the middle of the secondmetacarpal bone.
Abductor digitiminimi
Midbelly at the midpoint of the fifthmetacarpal bone on the palmar side.
Opponens pollicis Midbelly of the muscle over the midpoint of
the first metacarpal bone.
Dorsal interosseus Midbelly of muscles at the midpoint of themetacarpals.
Guidelines*
Dystonia BTX-A BTX-B Starting
DoseTotal maximum bodydose/visit
300 10,00015,000
-
8/10/2019 Botulinum Toxin Injection Guid
91/207
Muscles possibly involved Writers Cramp 3/3Flexor digitorum profundus Extensor digitorum
Flexor carpi radialis Extensor carpi ulnarisFlexor digitorum superficialis Extensor pollicis longusFlexor carpi ulnaris Extensor pollicis brevisPronator teres Extensor indicisPronator quadratus Adductor pollicis Opponens pollicisFlexor pollicis longus Abductor digiti minimi Dorsal interosseus
Dorsal interossei
Adductorpollicis
Opponenspollicis
Abductordigiti minimi
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60 SPASTICITY/DYSTONIA: UPPER EXTREMITIES
Safety Information Update
At the time of this writing the U.S. Food & Drug Administration (FDA)has issued an early communication about an ongoing safety review ofbotulinum toxins type A and B. The FDA has received reports of sys-temic adverse reactions including respiratory compromise and deathfollowing the use of botulinum toxins types A and B for both FDA-approved and unapproved uses. The reactions reported are suggestiveof botulism, which occurs when botulinum toxin spreads in the bodybeyond the site where it was injected. The most serious cases had
outcomes that included hospitalization and death, and occurred mostlyin children treated for cerebral palsy-associated limb spasticity. Useof botulinum toxins for trea